The influence of peri-operative factors for accelerated discharge following laparoscopic colorectal surgery when combined with an enhanced recovery after surgery (ERAS) pathway.

Chand M, De’Ath HD, Rasheed S, Mehta C, Bromilow J, Qureshi T. Int J Surg. 2016 Jan;25:59-63.

What is already known:

The wide-ranging benefits, including reduced hospital length of stay (LoS), of both laparoscopic surgery and ERAS have been well established. Perioperative complications are known to increase hospital LoS and mortality.

What this paper adds:

This study included a broad range of surgical procedures performed by a single surgeon using a standardised operative and anaesthetic technique. Details of patient inclusion/exclusion or compliance to ERAS guidelines are not given but it is inferred that all patients, having been recruited consecutively during the trial period, were fully followed-up with no exclusions and that there was no deviation from ERAS guidelines. The study protocol mentions the use of diclofenac, apparently as standard, for all procedures including those involving anastomosis creation (around 80% of procedures) with a 1% anastomotic leak rate. Ten patients were noted to have had a post-operative complication prior to initial discharge of which nine were classed as minor (Clavien-Dindo classification I or II) and these patients were all discharged on day two or three. The statistical analysis, however, showed an adjusted odds ratio of 16.26 for patients suffering a complication being more likely to experience a delayed discharge from hospital. It was also suggested that the study was likely underpowered to look into the effect of complications upon hospital LoS. 27 patients (9%) required readmission, the reasons for which are not detailed. Increased BMI and duration of operation were also suggested as predictors for delayed discharge but these had adjusted odds ratios of 1.06 and 0.99 respectively and of limited clinical significance.

Ben Morrison, Guildford.


Do we really need the full compliance with ERAS protocol in laparoscopic colorectal surgery? A prospective cohort study.

Pisarska M, Pędziwiatr M, Małczak P, Major P, Ochenduszko S, Zub-Pokrowiecka A, Kulawik J, Budzyński A. Int J Surg. 2016 Dec;36(Pt A):377-382.

What is already known:

Higher compliance with all the ERAS elements have been shown to improve outcomes, including longer term oncological outcomes. Most single centre studies look at their population as one group, and compares to another control group, but this Polish study aimed to assess short term outcomes based purely on compliance. They split the patients into three groups – high compliance (>90%), medium (70-90%)and low compliance <70%.

What this paper adds:

This study adds further weight to the argument that increased compliance improves short term outcomes. But interestingly not just between low and high compliance but also between medium and high compliance.

Chris Jones, Guildford.


A Meta-Analysis: Postoperative Pain Management in Colorectal Surgical Patients and the Effects on Length of Stay in an Enhanced Recovery After Surgery (ERAS) Setting.

Chemali ME1, Eslick GD. Clin J Pain. 2017 Jan;33(1):87-92.

What is already known:

Well managed pain relief aims to minimise side-effects and enable the main goals of ERAS to be achieved, including early mobilisation and early nutrition.

What this paper adds:

Optimal analgesia is an essential part of a successful ERAS programme, so the authors should be commended for conducting this important review. They included 21 separate RCT’s of several different types of analgesia comparisons, eg Lidocaine vs epidural, epidural vs PCA etc. This meta-analysis included colorectal RCT’s with pain as a major part of the study and length of stay as the main outcome. Overall they found no difference in their main outcome which was length of stay. However there are a number of flaws in this review. The studies they used were a mix of open and laparoscopic surgery, and not clear if all studies used a comprehensive ERAS programme as part of the standard care, in which case its difficult to draw accurate conclusions.

Chris Jones, Guildford.


Introducing an ERAS programme across a provincial healthcare system.

Nelson G, Kiyang LN, Crumley ET, Chuck A, Nguyen T, Faris P, Wasylak T, Basualdo-Hammond C, McKay S, Ljungqvist O, Gramlich LM. Implementation of Enhanced Recovery After Surgery (ERAS) Across a ProvincialHealthcare System: The ERAS Alberta Colorectal Surgery Experience. World J Surg. 2016 May;40(5):1092-103.

What is already known:

Most ERAS studies have been single centre and this is one of the first to describe how ERAS for colorectal surgery was implemented into a wider healthcare system in Alberta, Canada.

What this paper adds:

This study reports detailed results from six of Alberta’s 59 hospitals (but perform >70% of all colorectal surgery). After the ERAS programme was introduced compliance improved from 39% to 60%. They demonstrated an overall decrease in length of stay (6 to 5 days), readmissions, complications and some impressive cost savings (between $2806 and $5898 USD).

Chris Jones, Guildford.